Citation preview
pria_forms.pdf
Members of the National Air Transportation Association ~ Qualify
for 10% Discount off Background Check Service Items
SECTION A: COMPANY INFORMATION 1. Company Name 2. Client ID #
(required) 3. Address 4. City 5. State 6. Postal Code
7. Company Contact Name & Title
8. Email
9. Direct Phone & Extension 10. Secured Fax Number
SECTION B: EMPLOYEE / APPLICANT INFORMATION 1. Last Name 2. First
Name 3. Middle Name 4. Address 5. Birthdate * 6. City 7. State 8.
Postal Code
9. Position 10. Social Security Number *
SECTION C: REQUEST SERVICE TYPE (BACKGROUND CHECK PACKAGES)
SECTION D: ADDITIONAL SERVICES
SECTION E: SERVICE REPORTS METHOD OF DELIVERY / NOTES
9400 Gateway Drive, Suite D, Reno NV 89521 800.788.3210 voice |
800.682.1969 fax | 703.842.5317 int’l www.NATACS.aero
1.) 2 Year Drug & Alcohol History $69.95 • 2 Year DOT Drug
& Alcohol History
Check (Covers all DOT employers within 2-year period)
2) Basic PRIA Package 2 & 3 $199.95 • National Driver Registry
• 5 Year DOT Drug & Alcohol
History Check • FAA Records Check • Air Carrier Records Check
3) DASSP Airman $59.95 • DASSP Airman File
Check
1. U.S. Employment Verification per employer 1 & 3 $21.95 2.
Motor Vehicle Driving Record Check 1 & 3 $32.95
3. FAA Records Check $35.95 4. National Driver Registry 2
$49.95
5. Air Carrier Records Check per employer 3 $35.95 6. FAA
Certificate/License Check $29.95
7. 5 Year DOT Drug & Alcohol History Check per employer $39.95
8. FAA Accident, Incident and Enforcement (AIE) Report $59.95
All forms, verifications and reports are posted on www.NATACS.aero.
Company authorized contact may access via secured login. 1 A $25.90
application-processing fee will be charged for web-enabled services
per employee/applicant. 2 NDR documents with original signatures
must be MAILED to NATACS for processing. 3 Direct pass-through
expenses shall be invoiced. * If information has been previously
entered into the system, only the last four digits of the SSN are
required. If the employee/applicant is new to the system, the full
SSN and birthdate are required.
Questions? CALL +1.703.842.5317 FAX 1.866.768.2881 (alt)
1.800.682.1969 or
Email services@NATACS.aero or Mail: 9400 Gateway Drive, Suite D,
Reno, NV 89521
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!""#!78C#RSTSUVS#-VSUSW0#
9400 Gateway Drive, Suite D Reno, NV 89521 800.788.3210 voice
www.NATACS.aero
Drug and Alcohol History Check (ref: 49 CFR Part 40.25b) This
section requires DOT-regulated operator to check the record of the
new employees who were previously employed by a company subject to
DOT regulations.
Part I Section I: To be completed & signed by the
employee/applicant
PART I
I. EMPLOYEE/APPLICANT:
Employee Printed or Typed Name Employee Social Security
Number
1. I have been employed by one (or more) DOT-regulated company and
subject to DOT regulations within the last 5 years. (Check
one.)
Yes No
If “Yes”, provide name(s) of DOT-Regulated employer(s) and complete
the attached release form for each DOT-regulated company.
DOT-Regulated Employer:
DOT-Regulated Employer:
DOT-Regulated Employer:
DOT-Regulated Employer:
DOT-Regulated Employer:
2. I have tested positive, or refused to test, on any
pre-employment drug or alcohol test administered by a DOT-regulated
employer to which I have applied for, but did not obtain,
safety-sensitive transportation work covered by the DOT agency drug
and alcohol testing rules during the past two years. (Check
one.)
Yes No
Address:
City,State,Zip:
Phone:
Fax:
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INSTRUCTIONS
FAA FORM 8060-13, NATIONAL DRIVER REGISTER RECORDS REQUEST
(PRIA)
Pilot Records Improvement Act Of 1996 (PRIA) Title 49 U.S.C §
44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as
amended
Air carriers should use this form to request the appropri ate
records from the National Driver Registry as contemplated under 49
U.S.C. § 44 703(h). Complete Instructions for t he use of thi s
form, as well as proced ural information concerning the request of
NDR records, are provided on the official PRIA website as listed
below.
NOTICE Request will not be deemed valid unless Parts I, II, and III
are completed as specified below. This form may be photocopied for
use. This form is available on the Internet at
http://www.faa.gov/pilots/lic_cert/pria/ or
http://www.forms.faa.gov/ A separate form must be used for each
airman whose records are requested. Use of the date of birth,
social security number, or other information for which there may be
a reasonable expectation of privacy, is optional. However, use of
this information, at the applicant’s discretion, could facilitate
the retrieval of the appropriate records required by this request
IAW PRIA. (See the Privacy Act Statement)
Part I – National Driver Register (NDR) Records Request: To be
completed by the hiring Air Carrier. All entries must be completed
legibly with black or dark blue ink.
The hiring air carrier enters their name and air carrier
certificate number. Personal information concerning the applicant
is then entered into the respective spaces, with the date-of-birth
and social security number being disclosed ONLY at the discretion
of the applicant. The air carrier must ensure that complete mailing
instructions are included with this request. Part II – Consent To
The Release Of Records: To be completed by the applicant. All
entries must be completed legibly with black or dark blue ink. The
applicant must read and understand the statement, and then
authorize the request and release of the appropriate NDR records by
signing and dating the form in the indicated spaces. A notarized
signature MAY be required by the state. Part III – Notice To The
Prospective Employee. The air carrier representative must ensure
that the applicant is aware that a request for the appropriate NDR
records will be made IAW PRIA, and that a copy of the records, once
received, will be furnished to the applicant if they so desire. A
legible copy of this form must be furnished to the applicant after
being completed and signed. ID verification in III(a) is to be
completed by the air carrier representative when the application is
made in person. ID verification in III(b) is to be completed when
the application is NOT made in person. The respective state MAY
also require a notarized signature.
PAPERWORK REDUCTION ACT STATEMENT Title 49 United States Code (49
U.S.C.) § 44703 (h), Records of Employment of Pilot Applicants, as
amended, requires all air carriers to request FAA records and Air
Carrier and Other Records concerning an individual before allowing
that individual to begin service as a pilot. 49 U.S.C. § 44703 (h)
(8) requires the FAA Administrator to promulgate standard forms to
request records. The information entered on the standard forms will
be used to facilitate the search and retrieval of the required
records. It is estimated that the average burden per respondent
associated with this collection of FAA Records is 10 minutes. The
requirement to collect and evaluate background information on the
pilot, before allowing that pilot to begin service, is mandatory;
however, the use of this form is not, although it is highly
recommended. An agency may not conduct or sponsor, and a person is
not required to respond to, this request for information unless a
current and valid OMB control number is prominently displayed. The
OMB control number assigned to this collection is 2120-0607.
SEE PRIVACY ACT INFORMATION BELOW
FAA Form 8060-13 (10-05)
PRIVACY ACT STATEMENT: This statement is provided pursuant to the
Privacy Act of 1974, 5 USC § 552a: The authority for collecting
this information is contained in 49 U.S.C. §§ 40113, 44702, 44703,
44709. The principal purpose for which the information is intended
to be used is to identify and evaluate your qualifications and
eligibility for the issuance of an airman certificate and/or
rating. Submission of the data is mandatory, except for the Social
Security Number, which is voluntary. Failure to provide all
required information will result in our being unable to issue you a
certificate and/or rating. The information collected on this form
will be included in a Privacy Act System of Records known as
DOT/FAA 847, titled “Aviation Records on Individuals” and will be
subject to the routine uses published in the System of Records
Notice (SORN) for DOT/FAA 847 (see
www.dot.gov/privacy/privacyactnotices), including: (a) Providing
basic airmen certification and qualification information to the
public upon request; examples of basic information include: • The
type of certificates and ratings held, limitations, date of
issuance and certificate number; • The status of the airman’s
certificate (i.e., whether it is current or has been amended,
modified, suspended or revoked for any reason); • The airman’s home
address, unless requested by the airman to be withheld from public
disclosure per 49 U.S.C. 44703(c); • Information relating to an
airman’s physical status or condition used to determine
statistically the validity of FAA medical standards; and the date,
class, and restrictions of the latest physical • Information
relating to an individual’s eligibility for medical certification,
requests for exemption from medical requirements, and requests for
review of certificate denials. (b) Using contact information to
inform airmen of meetings and seminars conducted by the FAA
regarding aviation safety. (c) Disclosing information to the
National Transportation Safety Board (NTSB) in connection with its
investigation responsibilities. (d) Providing information about
airmen to Federal, State, local and tribal law enforcement agencies
when engaged in an official investigation in which an airman is
involved. (e) Providing information about enforcement actions, or
orders issued thereunder, to Federal agencies, the aviation
industry, and the public upon request. (f) Making records of
delinquent civil penalties owed to the FAA available to the U.S.
Department of the Treasury and the U.S. Department of Justice (DOJ)
for collection pursu- ant to 31 U.S.C. 3711(g). (g) Making records
of effective orders against the certificates of airmen available to
their employers if the airmen use the affected certificates to
perform job responsibilities for those employers. (h) Making airmen
records available to users of FAA’s Safety Performance Analysis
System (SPAS), including the Department of Defense Commercial
Airlift Division’s Air Car- rier Analysis Support System (ACAS) for
its use in identifying safety hazards and risk areas, targeting
inspection efforts for certificate holders of greatest risk, and
monitoring the effectiveness of targeted oversight actions. (i)
Making records of an individual’s positive drug test result,
alcohol test result of 0.04 or greater breath alcohol
concentration, or refusal to submit to testing required under a
DOT-required testing program, available to third parties, including
current and prospective employers of such individuals. Such records
also contain the names and titles of indi- viduals who, in their
commercial capacity, administer the drug and alcohol testing
programs of aviation entities. (j) Providing information about
airmen through the Civil Aviation Registry’s Comprehensive Airmen
Information System to the Department of Health and Human Services,
Office of Child Support Enforcement, and the Federal Parent Locator
Service that locates noncustodial parents who owe child support.
Records in this system are used to identify airmen to the child
support agencies nationwide in enforcing child support obligations,
establishing paternity, establishing and modifying support orders
and location of obligors. Records listed within the section on
Categories of Records are retrieved using Connect: Direct through
the Social Security Administration’s secure environment. (k) Making
personally identifiable information about airmen available to other
Federal agencies for the purpose of verifying the accuracy and
completeness of medical information provided to FAA in connection
with applications for airmen medical certification. (l) Making
records of past airman medical certification history data available
to Aviation Medical Examiners (AMEs) on a routine basis so that
AMEs may render the best medical certification decision. (m) Making
airman, aircraft and operator record elements available to users of
FAA’s Skywatch system, including the Department of Defense (DoD),
the Department of Homeland Security (DHS), DOJ and other authorized
Federal agencies, for their use in managing, tracking and reporting
aviation-related security events. (n) Other possible routine uses
published in the Federal Register (see Prefatory Statement of
General Routine Uses for additional uses (65 F.R. 19477-78) For
example, a record from this system of records may be disclosed to
the United States Coast Guard (Coast Guard) and to the
Transportation Security Administration (TSA) if information from
this system was shared with either agency when that agency was a
component of the Department of Transportation (DOT) before its
transfer to DHS and such disclosure is necessary to accomplish a
DOT, TSA or Coast Guard function related to this system of
records.
FAA Form 8060-13 (10-05)
REGISTER RECORDS CHECK (NDR)
Who: State of Florida Department of Highway Safety and Motor
Vehicles will no longer process out-of-state Requests for National
Driver Register (NDR) File Checks on Current or Prospective
Employee of Air Carriers.
What: Processing of NDR will require a New Form 8060-13, available
via http://info.natacs.aero/support/order-forms
When: Starting October 25, 2016, NATACS will no longer process the
State of Florida NDR form.
Where: New Form 8060-13 is available via
http://info.natacs.aero/support/order- forms
How: All requests must use form 8060-13 and *** ALL requests must
be notarized ***
Why: This new process will REDUCE the turn time for employers to
receive results.
Need Assistance? Call 1.703.842.5317 or email
info@NATACS.aero
NATIONAL DRIVER REGISTER RECORDS REQUEST (PRIA) Pilot Records
Improvement Act Of 1996 (PRIA)
Title 49 U.S.C. § 44703(h), RECORDS OF EMPLOYMENT OF PILOT
APPLICANTS, as amended
Pursuant to 49 U.S.C. § 44703(h)(5), the NDR, as a person who
receives a request for records under 49 U.S.C. § 44703(h)(1)(C),
shall furnish a copy of the requested NDR records concerning all
applicants, not later than 30 days after receiving the
request.
PART I: NATIONAL DRIVER REGISTER (NDR) RECORDS REQUEST This request
authorizes the National Highway Traffic Safety Administration
(NHTSA) to perform a one-time file search of the National Driver
Register (NDR) for information pertaining to me, and to provide the
results to the prospective employer listed below. This search is to
be limited to information about revocations or suspensions still in
effect on the date of the request or information entered into the
NDR in the past 5 years from the date of the employment
application. Upon my written request, the prospective employer
listed below shall make available to me any NDR information
received as a result of this search.
_______________________________________________ ,
________________________ , hereby requests records pertaining to:
(Air Carrier Name) (Air Carrier Certificate #)
____________________________________ , ___________________________
, _____________________________ (Full Legal Name – first, middle,
last) (Date Of Birth) (Social Security Number – optional)
________________________________________________________________________________________________
(Other Names Used – maiden prior name, nickname, professional name,
other. If none, enter ‘none’)
______________________________________ , _______ , _______________
, _______________ , _____________ (Driver License Number and State)
(Gender) (Eye Color) (Height) (Weight)
________________________________________________________________________________________________
(Mail the completed report to the requesting air carrier at this
address) PART II: CONSENT TO THE RELEASE OF RECORDS Prospective
Employee Understanding: I understand that the National Driver
Register (NDR) search will result in a printed report, which shall
be sent only to the prospective employer listed on this form. The
report will indicate either: (1) that the NDR does not contain a
records matching my identification; or, (2) that the NDR has a
probable identification (pointer record) from one or more states,
which will be named on this report. A separate and additional check
of state files, as a result of the pointer record, would be
required: (1) to verify the identification; or, (2) to obtain the
driving record. Under the Privacy Act, I have the right to request
records pertaining to me from the NDR to verify their
accuracy.
With my notarized signature, (If notarization is required) I hereby
authorize a one-time file search of NDR related records pertaining
to me, with any and all resulting reports to be sent to the
prospective employer named in Part I of this form.
__________________________________________________________________
______________________________ (Signature Of Applicant) (Date Of
Signature)
PART III: NOTICE TO THE PROSPECTIVE EMPLOYEE Pursuant to Title 49
(U.S.C.) § 44703(h)(6) Records of Employment of Pilot Applicants,
as amended, you are hereby notified, by being provided with a
completed copy of this form, that the above air carrier will submit
an FAA Records Request (PRIA) for your NDR related records. You are
also notified of your right to receive a copy of any and all such
records furnished by the NDR.
III(a). For Official ID Verification III(b). Notarization Date
Received: Date Sent: Internal Control: Required only if the NDR
File Check Request is NOT made in
person by the prospective employee, or by the respective state.
___Valid Photo Driver License ___State Issued Photo ID ___Birth
Certificate ___Valid Passport ___Valid Military ID ___Military
Discharge ___Other
___________________________________________
(Indicate the specific type of identification used.)
___________________________________________________ Printed name
and signature of person verifying identification.
Sworn to and ascribed before me this_____day of __________ In the
city/county of_______________________state of_____
Signature of Notary Public_____________________________ Notary
Public Seal:
NATA Compliance Services, 9400 Gateway Drive, Suite D, Reno NV
89521
C/O NATA Compliance Services
Airman Certificate Number:
YES 2: Off
NO 2: Off
NO 3: Off
YES 3: Off
YES 4: Off
NO 4: Off
Air Carrier Representative:
8 Email:
Date Of Birth:
Social Security Number optional:
Other Names Used maiden prior name nickname professional name other
If none enter none:
Driver License Number and State:
Gender:
Height:
Weight:
Mail the completed report to the requesting air carrier at this
address:
Date Received:
Date Sent:
Internal Control:
In the citycounty of:
undefined: